2. What’s disease management
Effectiveness
Preventive and curative interventions
Efficiency
Increase the quality of care
Reduce the global cost
Promoting patient or family self management
3. Health care environement
• GPs care for and encourage patient
to join disease management
program.
• Nurses, physical therapist,
nutritionist, physical trainer, social
worker and other care takers
• Patient and family have the key role
4. Success of disease
management
• Reducing costs by
• Prevention of complications
• Reducing hospitalization or re-hospitalization
• Reducing MD specialist encounters
• Participation in HMOs or managed care
• Increasing the effectiveness, efficiency
• Following best practice
• Education and training
5. Hospitals are also concerned
• Not only when the patient is discharge
• During hospital stays:
• Critical pathways
• Evidence based
• Nurses are best positioned to manage the
stay and prepare the discharge.
• Coordinate care after discharge from multi-
discipline team
6. Nurses’ roles
• Caring and prevention
• Coordination across the health
care provider team
• Do patient and family education
• Conduct research
• Contribute to evidence based
7. Nurses’ roles
• In Gonseth et al. study, nurses play a key
role in the follow up for patient with heart
failure or cardiovascular causes
• In the 27 studies screened 18 reported that
nurses played a central role in the disease
management
• 30% reduction of re-hospitalization over 3160
patients
8. Training
• For patient education, nurses need
competencies in:
• Evidence based
• Clinical research
• Prevention
• Psychosocial aspects
• PHR structure and goals
• EHR structure and goals
9. Role of IT
• Personal health record allows the
patient to:
• Self monitor
• Communicate
• Record
• Empower decision
11. References
• Gaspoz JM. Rutschmann O Faut-il avoir peur du disease management 1 Volet hopistalier
Revue médicale Suisse. Revue-medhyg.ch revue.medhyg.ch/article.php3?sid=30798
accessed 30.01.2010
• Goldstein P. Impact on disease management programs on hospital and community
nursing Practice. CNE series. Nursing Economics (Nov-Dec) 2006 vol. 24 no 6 pp 308-
313
• Gonseth J. Guallar-Castillon P, Banegas J.R, Rodrıguez-Artalejo F, The effectiveness of
disease management programmes in reducing hospital re-admission in older patients
with heart failure: a systematic review and meta-analysis of published reports. Elsevier
Ltd European Heart Journal (2004) 25, 1570–1595
• Fletley Brennan P. Promotion Health through better Personal Health Information
Management. HIMSS Atlanta March 2010
• Rutschmann O. Gaspoz JM. Faut-il avoir peur du disease management 2 Volet
ambulatoire Revue médicale Suisse. Revue-medhyg.ch
revue.medhyg.ch/article.php3?sid=30799 accessed 30.01.2010
• Vinne van der E. The ultimate goal of disease management: improved quality of life by
patient centric care. International Journal of Integrated Care – Vol. 9, 10 August 2009 –
ISSN 1568-4156 – http://www.ijic.org/ accessed 30.01.2010